Service Request

CUSTOMER SUPPORT 787-363-0729

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Has the equipment been disinfected (Endoscopes Only)

Yes

Service Issue: *

Leak Test (Endoscopes only)

Pass

Fail

Serial Number # *

Model number # *

Type Of Equipment

Please fill in form and return with equipment to be repaired:

Service Request

To Submit a Repair Request, please complete the form below. Either Print, complete and fax to 787-3630729 or simply fill in and submit. EMS will respond as quickly as possible to your request

Facility Name *

Email: *

Person to Contact about Repair

Purchase Order Number:

Disinfectant ( Endoscopes Only)

Gluteraldehyde

OPA

Peracetic Aicd

Other